MedicaidPrior AuthHigh impact
Community Behavioral Health Rehabilitative Services - MEDICAID - OHIO (New)
Humana·OH · Psychiatry, Pediatrics·Medicaid
Effective date
Jul 1, 2026
We identified it
Jun 30, 2026
Summary
Humana Healthy Horizons Ohio has established a new Medicaid prior authorization policy for Community Behavioral Health Rehabilitative Services (CPST, TBS, PSR) effective July 1, 2026. The policy requires prior authorization for specified services, mandates minimum 90-day authorization periods for approved services, and establishes submission timelines (2 days expedited, 7 days standard) to prevent claim denials. Providers must submit medical necessity documentation using Ohio Department of Medicaid forms and follow a hierarchy of clinical guidelines (OAC Chapter 5160, MCG, ASAM criteria).
Action Required
By June 1, 2026 (review date): (1) Billing team must identify all behavioral health codes requiring prior authorization by accessing the Ohio Medicaid Prior Authorization and Notification List on Humana's provider portal at https://provider.humana.com/medicaid/ohio-medicaid/clinical-coverage-policies. (2) Update billing software and EMR systems to enforce prior authorization requirements for CPST (Community Psychiatric Supportive Treatment), TBS (Therapeutic Behavioral Services), and PSR (Psychosocial Rehabilitation) services. (3) Establish submission workflows requiring authorization requests 7 days prior for standard determinations and 2 days prior for expedited requests to avoid exhausting approved service limits. (4) Modify encounter forms and templates to require providers document medical necessity using criteria from OAC Chapter 5160, MCG guidelines, or ASAM placement criteria before submission. (5) Train all billing and clinical staff on the 90-day minimum authorization period requirement and KX crisis modifier exclusion rules. (6) Ensure front desk and scheduling staff verify prior authorization status before appointments. Failure to obtain prior authorization prior to service delivery will result in financial penalties to the practice and reduced member benefits; services provided without preauthorization are subject to retrospective medical necessity review and potential claim denial.